Breathwork and/or Sound Healing

Intake & Consent Form

Please take a moment to complete this form before your session. Your responses help ensure a safe, supportive, and personalized experience. All information will be kept confidential.

Personal & Health Information

First name

Last name

Birthday

Month

Day

Year

Phone

Emergency Contact

Do you have any injuries, illnesses, or physical limitations that might affect your participation? Check all that apply

Aneurysms

Cardiovascular issues (e.g., high blood pressure, heart disease)

Epilepsy or seizures

Respiratory problems (e.g Asthma)

Bipolar disorder, Mania, PTSD, or other mental health conditions

Other

If you selected 'Other' in the previous question, please specify

Do you have any ongoing medical treatments or medications I should be aware of? Please share if applicable

Breathwork and/or Sound Healing

Intake & Consent Form

Personal & Health Information

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